State Of Emergency

He was stabbed during a racial melee in Brooklyn--but his problems didn't end there. Yankel Rosenbaum was taken to the emergency room of Kings County Hospital, where residents treated one stab wound but allegedly failed to notice another for 45 minutes. Later that night, the 29-year-old student died in surgery, having lost more than a quart of blood As the Brooklyn district attorney's office began a criminal investigation into the ER's conduct, one weary hospital official told a tabloid reporter: "It was just a very, very busy night."

The nights--and days--are perilously busy at emergency rooms everywhere. Overburdened, understaffed and glutted with patients suffering minor ailments, ERs themselves have become prime victims of the nation's health-care problems. As more Americans with little or no insurance use them in place of family physicians, and more facilities hemorrhage money from unreimbursable care, hospitals are desperate to find ways to treat true trauma cases and still serve those patients who have nowhere else to go. Many are now devising strategies to alleviate overcrowding and target their resources to those most in need. The most controversial plans involve reducing "inappropriate use" of ERs for everything from sunburns to hangnails.

The very idea troubles some physicians: "The last thing I want is for people to wonder whether they are sick enough to go to the emergency room," says Dr. John Johnson, president of the American College of Emergency Physicians. "We want to be their health-care safety net." But other doctors on the front lines say drastic action is necessary to get noncritical patients seen in more appropriate settings, and to free ER resources to help those most in need. "We're not God," says Dr. Robert Derlet, director of the emergency department at the University of California, Davis, Medical Center in Sacramento. "We can't take care of everybody."

Derlet's solution is among the most radical: UC, Davis simply turns away people who don't need real emergency care. The process begins at a triage desk, where a nurse makes a preliminary evaluation based on a patient's medical condition, regardless of ability to pay. Children under 15 are automatically seen; so is anyone brought in by ambulance and anyone with chest or abdominal pain. Those with less urgent complaints go to a screening desk where staffers refer them to community clinics or private physicians. In the last three years, Davis's ER has seen about 135,000 patients and sent about 20,000 elsewhere. Critics charge that the practice comes close to violating the Hippocratic oath. But Derlet contends there have been only minor protests from patients--and no lawsuits. Javier Hernandez, who came in with a toothache last week, wasn't complaining. "I understand there are too many patients to handle, too many real emergencies," said the uninsured musician, who was referred to a dental clinic.

Johns Hopkins University Hospital in Baltimore purchased its own Urgent Care Clinic in 1985 to help handle the ER overload. At the hospital patients are evaluated at a triage desk, and those with the least urgent needs are offered transportation, via shuttle bus, to the clinic, about a mile away. "We can be aggressive about triage because we are sending [patients] to ourselves," says emergency director Dr. Keith Sivertson. Visiting the ER represents the only contact many indigent patients ever have with the health-care system, so Hopkins staffers also put them in touch with a broad range of community services, from drug-counseling programs to prenatal care clinics, where they might receive more appropriate care. To ensure continuity in that care, Maryland instituted a program last March requiring all state Medicaid recipients to designate a primary-care physician.

Officials at Parkland Memorial Hospital in Dallas have gone even further, establishing an extensive network of Community Oriented Primary Clinics (COPC) to provide alternative services. "You have to create systems of care, not just eligibility programs," says Parkland president Dr. Ron Anderson. Last year Anderson helped avert a potential crisis when two other Dallas hospitals threatened to close their trauma centers, leaving Parkland alone to serve nearly 2 million Dallas County residents. After a series of negotiations, Methodist Medical Center and Baylor University Medical Center agreed to serve as backups to Parkland on designated days, and five other area hospitals agreed to take trauma patients when those hospitals are overloaded. "They didn't want to do it," says Anderson. "But it was a choice of being up to their waist later or being up to their ankles now." The COPC program sees some 35,000 new patients a year and provides 24-hour bilingual phone consultations. "We still have an overcrowded ER," says Dr. Michael Krentz, who runs the facility. "But I can't fathom how bad it would be if we didn't have these other avenues open to us."

Providing alternative care for nonemergency patients addresses only part of the ER problem. There is also an urgent need for more critical-care services, particularly as more hospitals eliminate emergency care altogether. In Congress, Rep. Brian Donnelly of Massachusetts has proposed a bill to require all nonprofit hospitals to maintain emergency rooms. About 60 designated trauma centers--specially equipped to handle severe injury cases--have closed in the past five years, leaving only some 370 serving the whole country. Already teeming with gunshot wounds, drug cases and indigent patients, Jackson Memorial Hospital in Miami is the only Level I trauma center south of Orlando; seven other area hospitals have eliminated trauma services since 1987. "They just said, 'Screw the public'," complains Dr. Robert Zeppa, Jackson's chief of emergency services. "And there wasn't one damn voice in this community that said there might be a moral issue here." Since then, however, Dade County residents have rallied to Jackson's aid: voters last month approved a half-cent sales tax to help fund a new $27 million trauma center at the hospital, complete with four new operating rooms and a rooftop helipad.

Community support is vital to improving emergency care, ER directors all say. "You need to start providing some alternatives before you complain about the ER," says Parkland's Anderson, who is taking reform even further by pressing for a tax on vehicle registrations and handguns to help finance a proposed $250 million trauma-care system. Anderson says there is growing, if grudging, support for the idea from voters. "We're convincing them that if the system fails, you taxpayers'll pay for it," he says. Ordinary citizens are also beginning to realize that unless drastic measures are taken, they might someday be the next Yankel Rosenbaum, lying helplessly in an overcrowded ER on a long, busy night.

Emergency rooms saw go million patients in 1990-more than twice the number seen in 1960.

$8.3 billion worth of trauma care--for severe injuries--went unreimbursed in 1988.

Some 60 designated trauma centers have closed since 1986, leaving only about 370 nationwide.